Meta-analysis of laparoscopy-assisted distal gastrectomy with D2 lymph node dissection for gastric cancer

Comparison of the Biomechanical Properties between Healthy and Whole Human and Porcine Stomachs

Gastric cancer poses a societal and economic burden, prompting an exploration into the development of materials suitable for gastric reconstruction. However, there is a dearth of studies on the mechanical properties of porcine and human stomachs. Therefore, this study was conducted to elucidate their mechanical properties, focusing on interspecies correlations. Stress relaxation and tensile tests assessed the hyperelastic and viscoelastic characteristics of porcine and human stomachs. The thickness, stress-strain curve, elastic modulus, and stress relaxation were assessed. Porcine stomachs were significantly thicker than human stomachs. The stiffness contrast between porcine and human stomachs was evident. Porcine stomachs demonstrated varying elastic modulus values, with the highest in the longitudinal mucosa layer of the corpus and the lowest in the longitudinal intact layer of the fundus. In human stomachs, the elastic modulus of the longitudinal muscular layer of the antrum was the highest, whereas that of the circumferential muscularis layer of the corpus was the lowest. The degree of stress relaxation was higher in human stomachs than in porcine stomachs. This study comprehensively elucidated the differences between porcine and human stomachs attributable to variations across different regions and tissue layers, providing essential biomechanical support for subsequent studies in this field.

Emergency exploratory laparotomy and radical gastrectomy in patients with gastric cancer combined with acute upper gastrointestinal bleeding

BACKGROUND

Gastric cancer (GC) is a prevalent malignant tumor worldwide and ranks as the fourth leading cause of cancer-related mortality. Upper gastrointestinal bleeding (UGIB) is a frequent complication of GC. Radical gastrectomy and palliative therapy are widely used surgical procedures in the clinical management of GC. This study intends to probe the clinical efficacy and safety of radical gastrectomy and palliative therapy on the basis of exploratory laparotomy in patients with GC combined with UGIB, hoping to provide valuable information to aid patients in selecting the appropriate surgical intervention.

AIM

To investigate the clinical efficacy and safety of exploratory laparotomy + radical gastrectomy and palliative therapy in patients with GC and UGIB combined.

METHODS

A total of 89 GC patients admitted to the First Affiliated Hospital of the University of South China between July 2018 and July 2020 were selected as participants for this study. The 89 patients were divided into two groups: radical resection group (n = 46) treated with exploratory laparotomy + radical gastrectomy and Palliative group (n = 43) treated with palliative therapy. The study compared several variables between the two groups, including surgical duration, intraoperative blood transfusion volume, postoperative anal exhaust time, off-bed activity time, length of hospitalization, and incidence of complications such as duodenal stump rupture, anastomotic obstruction, and postoperative incision. Additionally, postoperative immune function indicators (including CD3+, CD4+, CD8+, CD4+/CD8+, and CD3+/HLADR+), immunoglobulin (IgG and IgM), tumor markers (CEA, CA199, and CA125), and inflammatory factors (IL-6, IL-17, and TNF-α) were assessed. The surgical efficacy and postoperative quality of life recovery were also evaluated. The patients were monitored for survival and tumor recurrence at 6 mo, 1 year, and 2 years post-surgery.

RESULTS

The results indicated that the duration of operation time and postoperative hospitalization did not differ between the two surgical procedures. However, patients in the radical resection group exhibited shorter intraoperative blood loss, anus exhaust time, off-bed activity time, and inpatient activity time than those in the Palliative group. Although there was no substantial difference in the occurrence of postoperative complications, such as duodenal stump rupture and anastomotic obstruction, between the radical resection group and Palliative group (P > 0.05), the radical resection group exhibited higher postoperative immune function indicators (including CD3+, CD4+, CD8+, etc.) and immunoglobulin levels (IgG, IgM) than the Palliative group, while tumor markers and inflammatory factors levels were lower than those in the radical resection group. Additionally, surgical efficacy, postoperative quality of life, and postoperative survival rates were higher in patients who underwent radical gastrectomy than in those who underwent palliative therapy. Moreover, the probability of postoperative tumor recurrence was lower in the radical gastrectomy group compared to the palliative therapy group, and these differences were all statistically significant (P < 0.05).

CONCLUSION

Compared to palliative therapy, exploratory laparotomy + radical gastrectomy can improve immune function, reduce the levels of tumor markers and inflammatory factors, improve surgical efficacy, promote postoperative quality of life recovery, enhance survival rates, and attenuate the probability of tumor recurrence.

Case Report: Transvaginal specimen extraction following totally laparoscopic D2 distal gastrectomy for gastric cancer in a patient with situs inversus totalis: with video

Because of its significant advantage of fast postoperative recovery, natural orifice specimen extraction surgery (NOSES) has attracted increasing attention worldwide. However, the NOSES in gastric cancer (GC) treatment still needs more clinical practice, especially for the rare anatomical anomaly. Situs inversus totalis (SIT) is a rare autosomal recessive anatomical anomaly with an incidence ranging between 1/8,000 and 1/25,000 births. We present a video of transvaginal specimen extraction following totally laparoscopic D2 distal gastrectomy performed in a 59-year-old woman known to have SIT. Preoperative investigations revealed that the patient had early GC at the antrum. A gastroscopy report from the local hospital showed signet-ring cell carcinoma. The preoperative computed tomography scan revealed irregular thickening of the gastric wall at the junction of the greater curvature and antrum without metastasis to the lymph nodes. In total, laparoscopic D2 distal gastrectomy was performed with transvaginal specimen extraction. Billroth II with Braun anastomosis was performed for reconstruction. The length of the operation was 240 min without intraoperative complications and with minimal blood loss of 50 ml. The patient was uneventfully discharged on postoperative Day 7. The final pathology confirmed signet-ring cell carcinoma confined to the mucosal muscle without metastasis in 16 lymph nodes. Transvaginal specimen extraction following totally laparoscopic D2 distal gastrectomy can be safely performed in patients with SIT and has similar surgical outcomes to usual laparoscopic gastrectomy.

Laparoscopic vs. Open Gastrectomy for Locally Advanced Gastric Cancer: A Propensity Score-Matched Retrospective Case-Control Study

Introduction: Minimally invasive surgery has been increasingly used in the treatment of gastric cancer. While laparoscopic gastrectomy has become standard therapy for early-stage gastric cancer, especially in Asian countries, the use of minimally invasive techniques has not attained the same widespread acceptance for the treatment of more advanced tumours, principally due to existing concerns about its feasibility and oncological adequacy. We aimed to examine the safety and oncological effectiveness of laparoscopic technique with radical intent for the treatment of patients with locally advanced gastric cancer by comparing short-term surgical and oncologic outcomes of laparoscopic versus open gastrectomy with D2 lymphadenectomy at two Western regional institutions. Methods: The trial was designed as a retrospective comparative matched case-control study for postoperative pathological diagnoses of locally advanced gastric carcinoma. Between January 2015 and September 2021, 120 consecutive patients who underwent curative-intent laparoscopic gastrectomy with D2 lymph node dissection were retrospectively recruited and compared with 120 patients who received open gastrectomy. In order to obtain a comparison that was as homogeneous as possible, the equal control group of pairing (1:1) patients submitted to open gastrectomy who matched those of the laparoscopic group was statistically generated by using a propensity matched score method. The following potential confounder factors were aligned: age, gender, Body Mass Index (BMI), comorbidity, ASA, adjuvant therapy, tumour location, type of gastrectomy, and pT stage. Patient demographics, operative findings, pathologic characteristics, and short-term outcomes were analyzed. Results: In the case-control study, the two groups were clearly comparable with respect to matched variables, as was expected given the intentional primary selective criteria. No statistically significant differences were revealed in overall complications (16.7% vs. 20.8%, p = 0.489), rate of reoperation (3.3% vs. 2.5%, p = 0.714), and mortality (4.2% vs. 3.3%, p = 0.987) within 30 days. Pulmonary infection and wound complications were observed more frequently in the OG group (0.8% vs. 4.2%, p < 0.01, for each of these two categories). Anastomotic and duodenal stump leakage occurred in 5.8% of the patients after laparoscopic gastrectomy and in 3.3% after open procedure (p = 0.072). The laparoscopic approach was associated with a significantly longer operative time (212 vs. 192 min, p < 0.05) but shorter postoperative length of stay (9.1 vs. 11.6 days, p < 0.001). The mean number of resected lymph nodes after D2 dissection (31.4 vs. 33.3, p = 0.134) and clearance of surgical margins (97.5% vs. 95.8%, p = 0.432) were equivalent between the groups. Conclusion: Laparoscopic gastrectomy with D2 nodal dissection appears to be safe and feasible in terms of perioperative morbidity for locally advanced gastric cancer, with comparable oncological equivalency with respect to traditional open surgery.

Laparoscopic gastrectomy for gastric cancer: has the time come for considered it a standard procedure?

Radical gastrectomy with an adequate lymphadenectomy is the main procedure which makes it possible to cure patients with resectable gastric cancer. A number of randomized controlled trials and meta-analysis provide phase III evidence that laparoscopic gastrectomy is technically safe and that it yields better short-term outcomes than conventional open gastrectomy for early-stage gastric cancer. At present, laparoscopic gastrectomy is considered a standard procedure for early-stage gastric cancer, especially in Asian countries. On the other hand, the use of minimally invasive techniques is still controversial for the treatment of more advanced tumours, principally due to existing concerns about its oncological adequacy and capacity to carry out an adequately extended lymphadenectomy. Additional high-quality studies comparing laparoscopic gastrectomy versus open gastrectomy for gastric cancer have been recently published, in particular concerning the latest results obtained by laparoscopic approach to advanced gastric cancer. It seems very useful to update the review of literature in light of these new evidences for this subject and draw some considerations.

Robotic versus laparoscopic gastrectomy for gastric cancer: an umbrella review of systematic reviews and meta-analyses

An umbrella review was performed to summarize literature data and to investigate benefits and harm of robotic gastrectomy (RG) compared to laparoscopic (LG) approach. To overcome the intrinsic limitations of laparoscopy, the robotic approach is claimed to facilitate lymph-node dissection and complex reconstruction after gastrectomy, to assure oncologic safety also in advanced gastric cancer. A literature search was conducted in PubMed, Cochrane and Embase databases for all meta-analyses published up to December 2019. The search strategy was previously published in a protocol. We selected fourteen meta-analyses comparing outcomes between LG and RG with curative intent in patients with diagnosis of resectable gastric cancer. We highlight that RG has a longer operation time, inferior blood loss, reduction in hospital stay and a more rapid recovery of bowel function. In meta-analyses with statistical significance the number of nodes removed in RG is higher than LG and the distal margin of resection is higher. There is no difference in terms of total complication rate, mortality, morbidity, anastomotic leakage, anastomotic stenosis, intestinal obstruction and in conversion rate to open technique. The safety and efficacy of robotic gastrectomy are not clearly supported by strong evidence, suggesting that the outcomes reported for each surgical technique need to be interpreted with caution, in particular for the meta-analyses in which the heterogeneity is large. Certainly, robotic gastrectomy is associated with shorter time to oral intake, lesser intraoperative bleeding and longer operation time with an acceptable level of evidence. On the other hand, the data regarding other outcomes are insufficient as well as non-significant, from an evidence point of view, to draw any robust conclusion.

East meets West: the initial results of laparoscopic gastric cancer resections with Eastern principles in a single Western centre - a propensity score-matched study

BACKGROUND

We compared the initial experience of totally laparoscopic gastric cancer surgery with Eastern principles with the results of propensity score-matched counterparts operated with open surgery.

METHODS

From 1163 patients stored in our database, 62 PSM patients were selected for this study. The quality control was assured with video documentation and standardisation of the procedures.

RESULTS

According to the distribution of age, comorbidities, and general health, patients in the LG and OG were well-balanced. Most of the patients in both groups had advanced gastric cancer (69.3%). In the OG, 67.8% of patients received a total gastrectomy, as well as 54.8% of patients in the LG. There was no significant difference in the postoperative mortality between groups. The recovery of bowel function was significantly faster, and postoperative pain was significantly decreased in the LG. Compared to the OG, the inflammatory response was significantly smaller in the LG. There was no significant difference in the overall survival between LG and OG patients.

CONCLUSION

We have shown that laparoscopic gastrectomy with Eastern principles can be safely introduced in a high-volume Western centre with sufficient laparoscopic training. We have also shown that laparoscopy offers a significant faster bowel function recovery, less postoperative pain, and a smaller inflammatory response.

Effect of endoscopic resection on short-term surgical outcomes of subsequent laparoscopic gastrectomy: a meta-analysis

BACKGROUND

Endoscopic resection (ER) might affect subsequent laparoscopic gastrectomy (LG) because of the electrical coagulation, but the effect remains controversial. The purpose of this meta-analysis was to analyze the effect of ER on the short-term surgical outcomes of subsequent LG.

MATERIALS AND METHODS

The PubMed, EMBASE, and Cochrane Library databases were searched to find eligible studies published from inception to March 21, 2021. Short-term surgical outcomes were compared between the ER-LG group and the LG-only group. The registration ID of this current meta-analysis on PROSPERO is CRD42021238031.

RESULTS

Nine studies involving 3611 patients were included in this meta-analysis. The LG-only group had a higher T stage (T1-T2: OR=2.42, 95% CI=1.09 to 5.34, P=0.03; T3-T4: OR=0.41, 95% CI=0.19 to 0.91, P=0.03) than the ER-LG group. The ER-LG group showed a shorter operation time than the LG-only group (MD=-5.98, 95% CI=-10.99 to -0.97, P=0.02). However, no difference was found in operation time after subgroup analysis of propensity score matching studies. No significant difference was found in intraoperative blood loss, time to first oral feeding, or postoperative hospital stay between the ER-LG group and the LG-only group. And no significance was found in overall complications (OR=1.16, 95% CI=0.89 to 1.50, P=0.27), complications of grade ≥ II (OR=1.11, 95% CI=0.71 to 1.73, P=0.64), complications of grade ≥ III b (OR=1.47, 95% CI=0.49 to 4.43, P=0.49) between the ER-LG group and the LG-only group.

CONCLUSIONS

ER did not affect subsequent LG in terms of short-term outcomes, and the ER-LG group might have a shorter operation time than the LG-only group.

Robotic gastric surgery: a monocentric case series and review of the literature

INTRODUCTION

The technical complexity of D2 lymphadenectomy and esophago-jejunal anastomosis are the main factors that limit the application of laparoscopic surgery in the treatment of gastric cancer. Robotic assisted gastric surgery provides potential technical advantages over conventional laparoscopy but an improvement in clinical outcomes after robotic surgery has not been demonstrated yet.

EVIDENCE ACQUISITION

Data from 128 consecutive patients who had undergone robotic gastrectomy for gastric cancer at our center institution from April 2017 to June 2020 where retrospectively reviewed from a prospectively updated database. A narrative review was then carried out on PubMed, Embase and Scopus using the following keywords: "gastric cancer," "robotic surgery," "robotic gastrectomy" and "robotic gastric surgery".

EVIDENCE SYNTHESIS

Ninety-eight patients underwent robotic distal gastrectomy and 30 underwent robotic total gastrectomy. The mean value of estimated blood loss was 99.5 ml. No patients required conversion to laparoscopy or open surgery. The median number of retrieved lymph nodes was 42. No tumor involvement of the proximal or distal margin was found in any patient. The median time to first flatus and first oral feeding was on postoperative day 3 and 5, respectively. We registered 6 leakages (4.6%), namely, 1 duodenal stump leakage and 5 anastomotic leakages. No 30-day surgical related mortality was recorded. The median length of hospital stay was 10.5 days (range 4-37).

CONCLUSIONS

Published data and our experience suggest that the robotic approach for gastric cancer is safe and feasible with potential advantages over conventional laparoscopy.

Laparoscopic versus open subtotal gastrectomy for gastric adenocarcinoma: cost-effectiveness analysis

Background

Laparoscopic subtotal gastrectomy (LSG) for cancer is associated with good perioperative outcomes and superior quality of life compared with the open approach, albeit at higher cost. An economic evaluation was conducted to compare the two approaches.

Methods

A cost–effectiveness analysis between LSG and open subtotal gastrectomy (OSG) for gastric cancer was performed using a decision‐tree cohort model with a healthcare system perspective and a 12‐month time horizon. Model inputs were informed by a meta‐analysis of relevant literature, with costs represented in 2016 Canadian dollars (CAD) and outcomes measured in quality‐adjusted life‐years (QALYs). A secondary analysis was conducted using inputs extracted solely from European and North American studies. Deterministic (DSA) and probabilistic (PSA) sensitivity analyses were performed.

Results

In the base‐case model, costs of LSG were $935 (€565) greater than those of OSG, with an incremental gain of 0·050 QALYs, resulting in an incremental cost–effectiveness ratio of $18 846 (€11 398) per additional QALY gained from LSG. In the DSA, results were most sensitive to changes in postoperative utility, operating theatre and equipment costs, as well as duration of surgery and hospital stay. PSA showed that the likelihood of LSG being cost‐effective at willingness‐to‐pay thresholds of $50 000 (€30 240) per QALY and $100 000 (€60 480) per QALY was 64 and 68 per cent respectively. Secondary analysis using European and North American clinical inputs resulted in LSG being dominant (cheaper and more effective) over OSG, largely due to reduced length of stay after LSG.

Conclusion

In this decision analysis model, LSG was cost‐effective compared with OSG for gastric cancer.

Laparoscopic versus open approach in gastrectomy for advanced gastric cancer: a systematic review

BACKGROUND

Additional studies comparing laparoscopic gastrectomy (LG) versus open gastrectomy (OG) for advanced gastric cancer (AGC) have been published, and it is necessary to update the systematic review of this subject.

OBJECTIVE

We conducted the meta-analysis to find some proof for the use of LG in AGC and evaluate whether LG is an alternative treatment for AGC.

METHOD

Randomized controlled trials (RCT) and high-quality retrospective studies (NRCT) compared LG and OG for AGC, which were published in English between January 2010 and May 2019, were search in PubMed, Embase, and Web of Knowledge by three authors independently and thoroughly. Some primary endpoints were compared between the two groups, including intraoperative time, intraoperative blood loss, harvested lymph nodes, first flatus, first oral intake, first out of bed, post-operative hospital stay, postoperative morbidity and mortality, rate of disease recurrence, and 5-year over survival (5-y OS). Besides, considering for this 10-year dramatical surgical material development between 2010 and 2019, we furtherly make the same analysis based on recent studies published between 2016 and 2019.

RESULT

Thirty-six studies were enrolled in this systematic review and meta-analysis, including 5714 cases in LAG and 6094 cases in OG. LG showed longer intraoperative time, less intraoperative blood loss, and quicker recovery after operations. The number of harvested lymph nodes, hospital mortality, and tumor recurrence were similar. Postoperative morbidity and 5-y OS favored LG. Furthermore, the systemic analysis of recent studies published between 2016 and 2019 revealed similar result.

CONCLUSION

A positive trend was indicated towards LG. LG can be performed as an alternative to OG for AGC.

Robotic versus laparoscopic gastrectomy for gastric cancer: protocol for umbrella review of systematic reviews and meta-analyses

INTRODUCTION

Laparoscopic surgery has been adopted in some parts of the world as an innovative approach to the resection of gastric cancers. However, in the modern era of surgical oncology, to overcome intrinsic limitations of the traditional laparoscopy, the robotic approach is advocated as able to facilitate the lymph node dissection and complex reconstruction after gastrectomy, to assure oncologic safety also in advanced gastric cancer patients. Previous meta-analyses highlighted a lower complication rate as well as bleeding in the robotic approach group when compared with the laparoscopic one. This potential benefit must be balanced against an increased time of intervention. The aim of this umbrella review is to provide a comprehensive overview of the literature for surgeons and policymakers in order to evaluate the potential benefits and harms of robotic gastrectomy (RG) compared with the laparoscopic approach for gastric cancer.

METHODS AND ANALYSIS

We will perform a comprehensive search of the PubMed, Cochrane and Embase databases for all articles published up to May 2019 and reference list of relevant publications for systematic review and meta-analyses comparing the outcomes of RG and laparoscopic gastrectomy in patients with gastric cancer. Studies will be selected by two independent reviewers based on prespecified eligibility criteria and the quality will be assessed according to AMSTAR (A MeaSurement Tool to Assess systematic Reviews) checklist. All information will be collected using piloted and standardised data-extraction forms in DistillerSR developed following the Joanna Briggs Institute's recommended extraction items.

ETHICS AND DISSEMINATION

This umbrella review will inform clinical and policy decisions regarding the benefits and harms of RG for treating gastric cancer. The results will be disseminated through a peer-reviewed publication, conference presentations and the popular press. Formal ethical approval is not required as primary data will not be collected.

PROSPERO REGISTRATION NUMBER

CRD42019139906.

Laparoscopic versus open gastrectomy for gastric cancer

Background

Compared with open gastrectomy (OG), laparoscopic gastrectomy (LG) for gastric cancer has achieved rapid development and popularities in the past decades. However, lack of comprehensive analysis in long-term oncological outcomes such as recurrence and mortality hinder its full support as a valid procedure. Therefore, there are still debates on whether one of these options is superior.

Aim

To evaluate the primary and secondary outcomes of laparoscopic versus open gastrectomy for gastric cancer patients

Methods

Two authors independently extracted study data. Risk ratio (RR) with 95% confidence interval (CI) was calculated for binary outcomes, mean difference (MD) or the standardized mean difference (SMD) with 95% CI for continuous outcomes, and the hazard ratio (HR) for time-to-event outcomes. Review Manager 5.3 and STATA software were used for the meta-analysis.

Results

Seventeen randomized controlled trials (RCTs) involving 5204 participants were included in this meta-analysis. There were no differences in the primary outcomes including the number of lymph nodes harvested during operation, severe complications, short-term and long-term recurrence, and mortality. As for secondary outcomes, compared with the OG group, longer operative time was required for patients in the LG group (MD = 58.80 min, 95% CI = [45.80, 71.81], P < 0.001), but there were less intraoperative blood loss (MD = − 54.93 ml, 95% CI = [− 81.60, − 28.26], P < 0.001), less analgesic administration (frequency: MD = − 1.73, 95% CI = [− 2.21, − 1.24], P < 0.001; duration: MD = − 1.26 days, 95% CI = [− 1.40, − 1.12], P < 0.001), shorter hospital stay (MD = − 1.37 days, 95% CI = [− 2.05, − 0.70], P < 0.001), shorter time to first flatus (MD = − 0.58 days, 95% CI = [− 0.79, − 0.37], P < 0.001), ambulation (MD = − 0.50 days, 95% CI = [− 0.90, − 0.09], P = 0.02) and oral intake (MD = − 0.64 days, 95% CI = [− 1.24, − 0.03], P < 0.04), and less total complications (RR = 0.81, 95% CI = [0.71, 0.93], P = 0.003) in the OG group. There was no difference in blood transfusions (number, quantity) between these two groups. Subgroup analysis, sensitivity analysis, and the adjustment of Duval’s trim and fill methods for publication bias did not change the conclusions.

Conclusion

LG was comparable to OG in the primary outcomes and had some advantages in secondary outcomes for gastric cancer patients. LG is superior to OG for gastric cancer patients.

Laparoscopic Resection for Adenocarcinoma of the Stomach or Gastroesophageal Junction Improves Postoperative Outcomes: a Propensity Score Matching Analysis

BACKGROUND

Minimally invasive resection for upper gastrointestinal tumors has been associated with favorable results. However, the role of laparoscopic surgery (LS) in the multimodal treatment of patients with advanced adenocarcinoma of the stomach or gastroesophageal junction needs further investigation.

METHODS

Clinicopathological data of patients who underwent gastrectomy between 2005 and 2017 were assessed. Outcomes of patients undergoing LS were compared with those of patients treated with a conventional open resection (OR) using a 1:1 propensity score matching analysis.

RESULTS

Curative resection for adenocarcinoma of the stomach or gastroesophageal junction was performed in 417 patients during the study period. Beginning in June 2014, the majority of patients underwent LS (n = 72) and they were matched with 72 patients who were treated with an OR. The majority of patients treated with LS (89%) had advanced cancer (UICC stages II and III) and 82% of them received neoadjuvant chemotherapy. LS was significantly associated with a higher number of harvested lymph nodes (26 (9-62) vs. 21 (4-46), P = .007), a lower 90-day major complication rate (13 vs. 26%, P = .035), and a lower length of hospital stay (14 vs. 16 days, P = .001). After a median follow-up time of 32 months, 1-year overall survival rate was higher after LS than after OR (93 vs. 74%, P = .126); however, results did not reach statistical significance.

CONCLUSION

LS for adenocarcinoma of the stomach or gastroesophageal junction is feasible and significantly reduces major postoperative morbidity resulting in a reduced length of hospital stay. Therefore, LS should be preferably considered for the curative treatment of patients with these malignancies.

Robotic-assisted gastrectomy for gastric cancer: a European perspective

Gastrectomy is the mainstay treatment for gastric cancer. To reduce the associated patient burden, minimally invasive gastrectomy was introduced in almost 30 years ago. The increase in the availability of surgical robotic systems led to the first robotic-assisted gastrectomy to be performed in 2002 in Japan. Robotic gastrectomy however, particularly in Europe, has not yet gained significant traction. Most reports to date are from Asia, predominantly containing observational studies. These cohorts are commonly different in the tumour stage, location (particularly with regards to gastroesophageal junctional tumours) and patient BMI compared to those encountered in Europe. To date, no randomised clinical trials have been performed comparing robotic gastrectomy to either laparoscopic or open equivalent. Cohort studies show that robotic gastrectomy is equal oncological outcomes in terms of survival and lymph node yield. Operative times in the robotic group are consistently longer compared to laparoscopic or open gastrectomy, although evidence is emerging that resectional surgical time is equal. The only reproducibly significant difference in favour of robot-assisted gastrectomy is a reduction in intra-operative blood loss and some studies show a reduction in the risk of pancreatic fistula formation.

Robot-assisted laparoscopic vs open gastrectomy for gastric cancer: Systematic review and meta-analysis

AIM

To evaluate the potential effectiveness of robot-assisted gastrectomy (RAG) in comparison to open gastrectomy (OG) for gastric cancer patients.

METHODS

A comprehensive systematic literature search using PubMed, EMBASE, and the Cochrane Library was carried out to identify studies comparing RAG and OG in gastric cancer. Participants of any age and sex were considered for inclusion in comparative studies of the two techniques independently from type of gastrectomy. A meta-analysis of short-term perioperative outcomes was performed to evaluate whether RAG is equivalent to OG. The primary outcome measures were set for estimated blood loss, operative time, conversion rate, morbidity, and hospital stay. Secondary among postoperative complications, wound infection, bleeding and anastomotic leakage were also analysed.

RESULTS

A total of 6 articles, 5 retrospective and 1 randomized controlled study, involving 6123 patients overall, with 689 (11.3%) cases submitted to RAG and 5434 (88.7%) to OG, satisfied the eligibility criteria and were included in the meta-analysis. RAG was associated with longer operation time than OG (weighted mean difference 72.20 min; P < 0.001), but with reduction in blood loss and shorter hospital stay (weighted mean difference -166.83 mL and -1.97 d respectively; P < 0.001). No differences were found with respect to overall postoperative complications (P = 0.65), wound infection (P = 0.35), bleeding (P = 0.65), and anastomotic leakage (P = 0.06). The postoperative mortality rates were similar between the two groups. With respect to oncological outcomes, no statistical differences among the number of harvested lymph nodes were found (weighted mean difference -1.12; P = 0.10).

CONCLUSION

RAG seems to be a technically valid alternative to OG for performing radical gastrectomy in gastric cancer resulting in safe complications.

Robot-assisted laparoscopic gastrectomy for gastric cancer

Phase III evidence in the shape of a series of randomized controlled trials and meta-analyses has shown that laparoscopic gastrectomy is safe and gives better short-term results with respect to the traditional open technique for early-stage gastric cancer. In fact, in the East laparoscopic gastrectomy has become routine for early-stage gastric cancer. In contrast, the treatment of advanced gastric cancer through a minimally invasive way is still a debated issue, mostly due to worries about its oncological efficacy and the difficulty of carrying out an extended lymphadenectomy and intestinal reconstruction after total gastrectomy laparoscopically. Over the last ten years the introduction of robotic surgery has implied overcoming some intrinsic drawbacks found to be present in the conventional laparoscopic procedure. Robot-assisted gastrectomy with D2 lymphadenectomy has been shown to be safe and feasible for the treatment of gastric cancer patients. But unfortunately, most available studies investigating the robotic gastrectomy for gastric cancer compared to laparoscopic and open technique are so far retrospective and there have not been phase III trials. In the present review we looked at scientific evidence available today regarding the new high-tech surgical robotic approach, and we attempted to bring to light the real advantages of robot-assisted gastrectomy compared to the traditional laparoscopic and open technique for the treatment of gastric cancer.

NOSE laparoscopic gastrectomies for early gastric cancer may reduce morbidity and hospital stay: early results from a prospective nonrandomized study

BACKGROUND

Natural orifice specimen extraction - NOSE laparoscopy is a promising technique that avoids mini-laparotomy, possibly reducing postoperative pain, wound infections and hospital stay. Recent systematic reviews have shown that postoperative morbidity associated with laparoscopically assisted gastrectomies is similar to that after open gastrectomies. More specifically, there is no difference in wound infection rate. The study objective was to evaluate whether postoperative morbidity and hospital stay may be reduced by transoral specimen extraction after laparoscopically assisted gastrectomy for early gastric cancer (EGC).

MATERIAL AND METHODS

A prospective, nonrandomized study was carried out starting in August 2012. Data from all patients operated on during the first year, with minimum 18 months follow-up, were collected to assess feasibility, oncologic results, postoperative morbidity, hospital stay and functional results. Overall, 14 patients were included and followed-up. After gastric resection, a 3 cm opening was created on the gastric stump, and the specimen, divided into three segments stitched one to each other, was sutured to the gastric tube and retrieved through the mouth.

RESULTS

Postoperative morbidity was 7.14% (1/14): one case of pneumonia. No wound infection occurred. The mean postoperative hospital stay was 4.7 ± 1.0 days.

CONCLUSIONS

NOSE laparoscopic subtotal gastrectomy is feasible and safe, with similar oncologic results as LAG, but decreased morbidity and hospital stay.

Robotic vs laparoscopic distal gastrectomy with D2 lymphadenectomy for gastric cancer: a retrospective comparative mono-institutional study

Background

Robotic surgery has been developed with the aim of improving surgical quality and overcoming the limitations of conventional laparoscopy in the performance of complex mini-invasive procedures. The present study was designed to compare robotic and laparoscopic distal gastrectomy in the treatment of gastric cancer.

Methods

Between June 2008 and September 2015, 41 laparoscopic and 30 robotic distal gastrectomies were performed by a single surgeon at the same institution. Clinicopathological characteristics of the patients, surgical performance, postoperative morbidity/mortality and pathologic data were prospectively collected and compared between the laparoscopic and robotic groups by the Chi-square test and the Mann-Whitney test, as indicated.

Results

There were no significant differences in patient characteristics between the two groups. Mean tumor size was larger in the laparoscopic than in the robotic patients (5.3 ± 0.5 cm and 3.0 ± 0.4 cm, respectively; P = 0.02). However, tumor stage distribution was similar between the two groups. The mean number of dissected lymph nodes was higher in the robotic than in the laparoscopic patients (39.1 ± 3.7 and 30.5 ± 2.0, respectively; P = 0.02). The mean operative time was 262.6 ± 8.6 min in the laparoscopic group and 312.6 ± 15.7 min in the robotic group (P < 0.001). The incidences of surgery-related and surgery-unrelated complications were similar in the laparoscopic and in the robotic patients. There were no significant differences in short-term clinical outcomes between the two groups.

Conclusions

Within the limitation of a small-sized, non-randomized analysis, our study confirms that robotic distal gastrectomy is a feasible and safe surgical procedure. When compared with conventional laparoscopy, robotic surgery shows evident benefits in the performance of lymphadenectomy with a higher number of retrieved and examined lymph nodes.

Outcomes of octogenarians undergoing gastrectomy performed for malignancy

BACKGROUND

Studies on perioperative outcomes of octogenarians with gastric cancer are limited by small sample size. Our aim was to determine the outcomes of gastrectomy and the variation of treatments associated with advanced age (≥80 y).

METHODS

The National Surgical Quality Improvement Program database was queried from 2005 to 2011. Patients who underwent gastrectomy for malignancy were identified using International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes.

RESULTS

Of 2591 cases, 487 patients were octogenarians (≥80) and 2104 were nonoctogenarians (<80). Overall, 4.9% of patients had disseminated cancer. Octogenarians had higher 30-d mortality (7.2% versus 2.5%, P < 0.01) and more major complications (31.4% versus 25.5%, P < 0.01), though fewer octogenarians underwent total gastrectomy (24.0% versus 43.2%, P < 0.01) and extended lymphadenectomy (10.1% versus 17.4%, P < 0.01) than the nonoctogenarian cohort. On multivariate analysis, age ≥80 y was associated with major complications (OR, 1.3; 95% CI, 1.03-1.6; P = 0.03) and increased mortality (OR, 3.0; 95% CI, 1.9-4.9; P < 0.01).

CONCLUSIONS

Advanced age (≥80 y) was associated with worse outcomes in patients undergoing gastrectomy for malignancy. Therefore, careful staging is necessary to reduce unnecessary operations in this population. Furthermore, surgeons must place greater attention on optimizing the octogenarian population before surgery.

Laparoscopic and robot-assisted gastrectomy for gastric cancer: Current considerations

Radical gastrectomy with an adequate lymphadenectomy is the main procedure which makes it possible to cure patients with resectable gastric cancer (GC). A number of randomized controlled trials and meta-analysis provide phase III evidence that laparoscopic gastrectomy is technically safe and that it yields better short-term outcomes than conventional open gastrectomy for early-stage GC. While laparoscopic gastrectomy has become standard therapy for early-stage GC, especially in Asian countries such as Japan and South Korea, the use of minimally invasive techniques is still controversial for the treatment of more advanced tumours, principally due to existing concerns about its oncological adequacy and capacity to carry out an adequately extended lymphadenectomy. Some intrinsic drawbacks of the conventional laparoscopic technique have prevented the worldwide spread of laparoscopic gastrectomy for cancer and, despite technological advances in recent year, it remains a technically challenging procedure. The introduction of robotic surgery over the last ten years has implied a notable mutation of certain minimally invasive procedures, making it possible to overcome some limitations of the traditional laparoscopic technique. Robot-assisted gastric resection with D2 lymph node dissection has been shown to be safe and feasible in prospective and retrospective studies. However, to date there are no high quality comparative studies investigating the advantages of a robotic approach to GC over traditional laparoscopic and open gastrectomy. On the basis of the literature review here presented, robot-assisted surgery seems to fulfill oncologic criteria for D2 dissection and has a comparable oncologic outcome to traditional laparoscopic and open procedure. Robot-assisted gastrectomy was associated with the trend toward a shorter hospital stay with a comparable morbidity of conventional laparoscopic and open gastrectomy, but randomized clinical trials and longer follow-ups are needed to evaluate the possible influence of robot gastrectomy on GC patient survival.

Comparison Between Minimally Invasive and Open Gastrectomy for Gastric Cancer in Europe: A Systematic Review and Meta-analysis

AIMS

We compared laparoscopic and robotic gastrectomies with open gastrectomies and with each other that were held for gastric cancer in Europe.

METHODS

We searched for studies conducted in Europe and published up to 20 February 2015 in the PubMed database that compared laparoscopic or robotic with open gastrectomies for gastric cancer and with each other.

RESULTS

We found 18 original studies (laparoscopic vs open: 13; robotic vs open: 3; laparoscopic vs robotic: 2). Of these, 17 were non-randomized trials and only 1 was a randomized controlled trial. Only four studies had more than 50 patients in each arm. No significant differences were detected between minimally invasive and open approaches regarding the number of retrieved lymph nodes, anastomotic leakage, duodenal stump leakage, anastomotic stenosis, postoperative bleeding, reoperation rates, and intraoperative/postoperative mortality. Nevertheless, laparoscopic procedures provided higher overall morbidity rates when compared with open ones, but robotic approaches did not differ from open ones. On the contrary, blood loss was less and hospital stay was shorter in minimally invasive than in open approaches. However, the results were controversial concerning the duration of operations when comparing minimally invasive with open gastrectomies. Additionally, laparoscopic and robotic procedures provided equivalent results regarding resection margins, duodenal stump leakage, postoperative bleeding, intraoperative/postoperative mortality, and length of hospital stay. On the contrary, robotic operations had less blood loss, but lasted longer than laparoscopic ones. Finally, there were relatively low conversion rates in laparoscopic (0%-6.7%) and robotic gastrectomies (0%-5.6%) in most studies.

CONCLUSION

Laparoscopic and robotic gastrectomies may be considered alternative approaches to open gastrectomies for treating gastric cancer. Minimally invasive operations are characterized by less blood loss and shorter hospital stay than open ones. In addition, robotic procedures have less blood loss, but last longer than laparoscopic ones.

Oncologic value of laparoscopy-assisted distal gastrectomy for advanced gastric cancer: A systematic review and meta-analysis

BACKGROUND:

The oncologic validity of laparoscopic-assisted distal gastrectomy (LADG) in the treatment of advanced gastric cancer (AGC) remains controversial. This study is a systematic review and meta-analysis of the available evidence.

MATERIALS AND METHODS:

A comprehensive search was performed between 2008 and 2014 to identify comparative studies evaluating morbidity/mortality, oncologic surgery-related outcomes, recurrence and survival rates. Data synthesis and statistical analysis were carried out using RevMan 5.2 software.

RESULTS:

Eight studies with a total of 1456 patients were included in this analysis. The complication rate was lower in LADG [odds ratio (OR) 0.59; 95% confidence interval (CI) = 0.42-0.83; P < 0.002]. The in-hospital mortality rate was comparable (OR 1.22; 95% CI = 0.28-5-29, P = 0.79). There was no significant difference in the number of harvested lymph nodes, resection margins, cancer recurrence rate, cancer-related mortality or overall and disease-free survival (OS and DFS, respectively) rates between the laparoscopic and the open groups (P > 0.05).

CONCLUSION:

The current study supports the view that LADG for AGC is a feasible, safe and effective procedure in selected patients. Adequate lymphadenectomy, resection margins, recurrence, cancer-related mortality and long-term outcomes appear equivalent to open distal gastrectomy (ODG).

Gastric cancer: Current status of lymph node dissection

D2 procedure has been accepted in Far East as the standard treatment for both early (EGC) and advanced gastric cancer (AGC) for many decades. Recently EGC has been successfully treated with endoscopy by endoscopic mucosal resection or endoscopic submucosal dissection, when restricted or extended Gotoda's criteria can be applied and D1+ surgery is offered only to patients not fitted for less invasive treatment. Furthermore, two randomised controlled trials (RCTs) have been demonstrating the non inferiority of minimally invasive technique as compared to standard open surgery for the treatment of early cases and recently the feasibility of adequate D1+ dissection has been demonstrated also for the robot assisted technique. In case of AGC the debate on the extent of nodal dissection has been open for many decades. While D2 gastrectomy was performed as the standard procedure in eastern countries, mostly based on observational and retrospective studies, in the west the Medical Research Council (MRC), Dutch and Italian RCTs have been conducted to show a survival benefit of D2 over D1 with evidence based medicine. Unfortunately both the MRC and the Dutch trials failed to show a survival benefit after the D2 procedure, mostly due to the significant increase of postoperative morbidity and mortality, which was referred to splenopancreatectomy. Only 15 years after the conclusion of its accrual, the Dutch trial could report a significant decrease of recurrence after D2 procedure. Recently the long term survival analysis of the Italian RCT could demonstrate a benefit for patients with positive nodes treated with D2 gastrectomy without splenopancreatectomy. As nowadays also in western countries D2 procedure can be done safely with pancreas preserving technique and without preventive splenectomy, it has been suggested in several national guidelines as the recommended procedure for patients with AGC.

Minimally invasive surgery for stomach cancer

Laparoscopic surgery for gastric cancer has become extremely widespread in recent years especially in Asian countries due to its low invasiveness. As to evidence of indication for laparoscopic surgery for gastric cancer, laparoscopic surgery for gastric cancer often appears to be indicated for early gastric cancer at many institutions, while evidence was considered to be insufficient to recommend laparoscopic surgery for gastric cancer at Stage II and above. There are also problems with indications for cases other than tumour factors. No meta-analyses and prospective studies have been reported, but outcomes of laparoscopic surgery for gastric cancer in gastric cancer patients with co-morbid and/or existing diseases have been reported in retrospective studies. Indications in the elderly appear to be favourable in terms of post-operative ambulation considering factors such as the degree of dissection in accordance with the status of the patient. Meta-analyses, randomized controlled trials and several retrospective studies have compared the short-term usefulness of laparoscopic surgery for gastric cancer with that of conventional gastrectomy. The superiority of laparoscopic surgery for gastric cancer has been reported in terms of the reduced amount of bleeding, a reduction in the administration frequency and period of analgesic doses, a reduction in the duration of fever, early recovery of intestinal movement and early return to oral intake. A small-scale randomized controlled trial and several retrospective studies have demonstrated no significant differences in survival rate, recurrence rate and type of recurrence between laparoscopic surgery for gastric cancer and conventional gastrectomy. The results of the aforementioned trials in early gastric cancer in Japan and Korea for which enrolment is complete remain to be published.

Beginner Surgeon's Initial Experience with Distal Subtotal Gastrectomy for Gastric Cancer Using a Minimally Invasive Approach

PURPOSE

Minimally invasive gastrectomy (MIG), including laparoscopic distal subtotal gastrectomy (LDG) and robotic distal subtotal gastrectomy (RDG), is performed for gastric cancer, and requires a learning period. However, there are few reports regarding MIG by a beginner surgeon trained in MIG for gastric cancer during surgical residency and fellowship. The aim of this study was to report our initial experience with MIG, LDG, and RDG by a trained beginner surgeon.

MATERIALS AND METHODS

Between January 2014 and February 2015, a total of 36 patients (20 LDGs and 16 RDGs) underwent MIG by a beginner surgeon during the learning period, and 13 underwent open distal subtotal gastrectomy (ODG) by an experienced surgeon in Bundang CHA Medical Center. Demographic characteristics, operative findings, and short-term outcomes were evaluated for the groups.

RESULTS

MIG was safely performed without open conversion in all patients and there was no mortality in either group. There was no significant difference between the groups in demographic factors except for body mass index. There were significant differences in extent of lymph node dissection (LND) (D2 LND: ODG 8.3% vs. MIG 55.6%, P=0.004) and mean operative time (ODG 178.8 minutes vs. MIG 254.7 minutes, P<0.001). The serial changes in postoperative hemoglobin level (P=0.464) and white blood cell count (P=0.644) did not show significant differences between the groups. There were no significant differences in morbidity.

CONCLUSIONS

This study showed that the operative and short-term outcomes of MIG for gastric cancer by a trained beginner surgeon were comparable with those of ODG performed by an experienced surgeon.

Laparoscopic surgery: A qualified systematic review

AIM: To review current applications of the laparoscopic surgery while highlighting the standard procedures across different fields.

METHODS: A comprehensive search was undertaken using the PubMed Advanced Search Builder. A total of 321 articles were found in this search. The following criteria had to be met for the publication to be selected: Review article, randomized controlled trials, or meta-analyses discussing the subject of laparoscopic surgery. In addition, publications were hand-searched in the Cochrane database and the high-impact journals. A total of 82 of the findings were included according to matching the inclusion criteria. Overall, 403 full-text articles were reviewed. Of these, 218 were excluded due to not matching the inclusion criteria.

RESULTS: A total of 185 relevant articles were identified matching the search criteria for an overview of the current literature on the laparoscopic surgery. Articles covered the period from the first laparoscopic application through its tremendous advancement over the last several years. Overall, the biggest advantage of the procedure has been minimizing trauma to the abdominal wall compared with open surgery. In the case of cholecystectomy, fundoplication, and adrenalectomy, the procedure has become the gold standard without being proven as a superior technique over the open surgery in randomized controlled trials. Faster recovery, reduced hospital stay, and a quicker return to normal activities are the most evident advantages of the laparoscopic surgery. Positive outcomes, efficiency, a lower rate of wound infections, and reduction in the perioperative morbidity of minimally invasive procedures have been shown in most indications.

CONCLUSION: Improvements in surgical training and developments in instruments, imaging, and surgical techniques have greatly increased safety and feasibility of the laparoscopic surgical procedures.

Demonstrating Value: A Case Study of Enhanced Recovery

An enhanced recovery after surgery strategy will be increasingly adopted in the era of value-based care. The various elements in each enhanced recovery after surgery protocol are likely to add value to the overall patient surgical journey. Although the evidence varies considerably based on type of surgery and patient group, the team-based approach of care should be universally applied to patient care. This article provides an overview of up-to-date techniques and methodology for enhanced recovery, including an overview of value-based care, delivery, and the evidence base supporting enhanced recovery after surgery.

Laparoscopic Versus Open Distal Gastrectomy With D2 Lymph Node Dissection for cT2 Gastric Cancer: A Retrospective Cohort Study of Short- and Long-Term Outcomes

The purpose of this study was to determine whether laparoscopy-assisted distal gastrectomy (LDG) with D2 lymphadenectomy could be a standard treatment for cT2N0-1 gastric cancer. There have been few reports regarding the long-term outcomes of patients with advanced gastric cancer who underwent LDG with D2 lymphadenectomy. The study included 32 patients who underwent LDG with D2 lymphadenectomy and 44 patients who underwent open distal gastrectomy (ODG) with D2 lymphadenectomy. There was no clinicopathologic difference in patient background between the groups. Operative duration was significantly longer in the LDG group than in the ODG group (297 ± 12 minutes versus 226 ± 10 minutes; P &lt; 0.001). However, blood loss was significantly less (90 ± 27 mL versus 314 ± 23 mL; P &lt; 0.001) and the number of days to assisted ambulation significantly shorter (1.1 ± 0.1 days versus 1.5 ± 0.1 days; P = 0.010) in the LDG group than in the ODG group. Median follow-up period was 60 months. The 5-year overall survival rates for the LDG group and the ODG group were 89.5% and 97.1%, respectively. The 5-year relapse-free survival rates for the LDG group and the ODG group were 88.0% and 97.7%, respectively. There were no significant differences in overall and relapse-free survival rates between the groups. LDG with D2 lymphadenectomy for cT2N0-1 gastric cancer is oncologically and technically safe and feasible, and is an option in the surgeon's arsenal. Randomized controlled study including the investigation of cost-effectiveness should be conducted.

Laparoscopic-assisted versus open distal gastrectomy with D2 lymph node resection for advanced gastric cancer: effect of learning curve on short-term outcomes. a meta-analysis

Laparoscopic-assisted distal gastrectomy (LADG) with D2 resection is gradually being performed for treating advanced gastric cancer. This meta-analysis aims to compare the clinical outcomes between LADG and open distal gastrectomy (ODG) when considering the impact of the learning curve. The PubMed, Embase, and ISI databases and the Cochrane Library were electronically searched. Randomized controlled trails and retrospective comparative studies published between 1994 and 2013 were collected. We divided the included studies into two subgroups according to whether the authors had experience of at least or fewer than 40 cases of LADG with D2 resection and then compared the operative time, intraoperative bleeding, the amount of resected lymph nodes, short-term recovery parameters, and complications between LADG and ODG groups. Ten comparative studies including 1100 patients were selected. Meta-analysis showed that when LADG was compared with ODG, surgeons with experience of at least 40 cases could achieve more resected lymph nodes (P=.002), reduced time to flatus (P<.0001), shortened time to liquid diet (P<.00001), and lower complication rates (P=.02). However, the above advantages of LADG faded in the subgroup of surgeons with experience of fewer than 40 cases. Our meta-analysis suggested that the learning curve has significant effects on most of the important surgical and short-term recovery outcome parameters. Accomplishment of 40 cases of LADG with D2 lymphadenectomy is required to achieve optimum proficiency.

Long-term survival outcomes of laparoscopic versus open gastrectomy for gastric cancer: a systematic review and meta-analysis

Many meta-analyses have confirmed the technical feasibility and favorable short-term surgical outcomes of laparoscopic gastrectomy (LG) for gastric cancer patients, but the long-term survival outcome of LG remains controversial compared with open gastrectomy (OG). This study aimed to compare the 5-year overall survival (OS), recurrence, and gastric cancer-related death of LG with OG among gastric cancer patients. PubMed was searched to February 2014. The resectable gastric cancer patients who underwent curative LG or OG were eligible. The studies that compared 5-year OS, recurrence, or gastric cancer-related death in the LG and OG groups were included. A meta-analysis, meta-regression, sensitivity analysis, subgroup analysis, and stage-specific analysis were performed to estimate the survival outcome between the two groups and identify the potential confounders. Quality assessment was based on a tailored comparability scoring system. Twenty-three studies with 7336 patients were included. The score of comparability between two groups and the extent of lymphadenectomy were two independent confounders. Based on the well-balanced studies, the 5-year OS (OR = 1.07, 95% CI 0.90-1.28, P = 0.45), recurrence (OR = 0.83, 95% CI 0.68-1.02, P = 0.08), and gastric cancer-related death (OR = 0.86, 95% CI 0.65-1.13, P = 0.28) rates were comparable in LG and OG. Several subsets such as the publication year, study region, sample size, gastrectomy pattern, extent of lymphadenectomy, number of nodes harvested, and proportion of T1-2 or N0-1 did not influence the estimates, if they were well balanced. Particularly, the stage-specific estimates obtained comparable results between the two groups. Randomized controlled trials comparing LG with OG remain sparse to assess their long-term survival outcomes. The major contributions of this systematic review compared with other meta-analyses are a comprehensive collection of available long-term survival outcomes within a much larger number of observations and a more precise consideration of confounders. Current knowledge indicates that the long-term survival outcome of laparoscopic gastric cancer surgery is comparable to that of open surgery among early or advanced stage gastric cancer patients, and LG is acceptable with regard to oncologic safety.

Laparoscopic total gastrectomy using the transorally inserted anvil (OrVil™): a preliminary, single institution experience

Laparoscopic total gastrectomy (LTG) is not a commonly performed procedure due to the difficulty associated with surgical reconstruction. We present our preliminary results after intracorporeal circular stapling esophagojejunostomy using the newly developed transorally inserted anvil (OrVil™, Covidien, MA, USA). Between 2008 and June 2013, 51 patients underwent laparoscopic gastrectomy with D2 lymph node dissection for gastric cancer. A total of 12 patients underwent LTG: of these, 5 received an intracorporeal linear side-to-side esophagojejunal anastomosis and the remaining 7 underwent intracorporeal circular stapling esophagojejunostomy using the OrVil™ system. Short-term outcomes were compared between the two groups. There were no intraoperative complications or conversions to open surgery in any patients. The mean operative time was significantly shorter in the OrVil™ than in the side-to-side group (261.4 ± 12.0 vs 333.0 ± 15.0 minutes, respectively, p = 0.005). Postoperative fluorography revealed no anastomosis leakage or stenosis in either groups. All patients resumed an oral liquid diet on postoperative day 5 and the mean postoperative hospital stay was 9 days. Intracorporeal circular stapling esophagojejunostomy using the OrVil™ system is technically feasible and safe in LTG. This technique may be considered a simple and time-saving alternative to the side-to-side linear esophagojejunostomy.

Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND

Application of evidence-based perioperative care protocols reduces complication rates, accelerates recovery and shortens hospital stay. Presently, there are no comprehensive guidelines for perioperative care for gastrectomy.

METHODS

An international working group within the Enhanced Recovery After Surgery (ERAS®) Society assembled an evidence-based comprehensive framework for optimal perioperative care for patients undergoing gastrectomy. Data were retrieved from standard databases and personal archives. Evidence and recommendations were classified according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system and were discussed until consensus was reached within the group. The quality of evidence was rated 'high', 'moderate', 'low' or 'very low'. Recommendations were graded as 'strong' or 'weak'.

RESULTS

The available evidence has been summarized and recommendations are given for 25 items, eight of which contain procedure-specific evidence. The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations.

CONCLUSION

The present evidence-based framework provides comprehensive advice on optimal perioperative care for the patient undergoing gastrectomy and facilitates multi-institutional prospective cohort registries and adequately powered randomized trials for further research.

Does overweight affect outcomes in patients undergoing gastrectomy for cancer? A meta-analysis of 25 cohort studies

OBJECTIVE

Overweight was regarded as one of the risk factors for poor outcome after gastrectomy, but its influence on the surgical and postoperative outcomes of gastrectomy was unclear.

METHODS

Comprehensive searches were conducted to include cohort studies which evaluated the influence of overweight on the surgical and postoperative outcomes of gastrectomy. Data was analyzed by RevMan 5.0.

RESULTS

Twenty-five cohort studies (18 518 patients) were included. Overweight patients were associated with longer operation time (mean difference 20.88, 95% confidence interval 14.07, 27.69), more intraoperative blood loss (mean difference 35.45, 95% confidence interval 9.24, 61.67), and less retrieved lymph nodes (mean difference -2.17, 95% confidence interval -3.51, -0.83) than normal patients undergoing laparoscopy-assisted gastrectomy. And overweight patients were associated with longer operation time (mean difference 26.31, 95% confidence interval 21.92, 30.70), more intraoperative blood loss (mean difference 130.02, 95% confidence interval 75.49, 184.55), less retrieved lymph nodes (mean difference -3.18, 95% confidence interval -4.74, -1.61), longer postoperative hospital stay (mean difference 2.37, 95% confidence interval 0.03, 4.70) and more postoperative complications (risk ratio 1.53, 95% confidence interval 1.29, 1.80) than normal patients in open gastrectomy.

CONCLUSIONS

Overweight might affect the clinical results of both laparoscopy-assisted and open gastrectomy, especially for open gastrectomy.

Systematic review of laparoscopy-assisted versus open gastrectomy for advanced gastric cancer

OBJECTIVE

The study compared laparoscopy-assisted gastrectomy (LAG) with open gastrectomy (OG) in the management of advanced gastric cancer (AGC).

METHODS

Literature search was performed in the Medline, Embase, and Cochrane Library databases to identify control studies that compared LAG and OG for AGC. A meta-analysis was conducted to examine the surgical safety and oncologic adequacy, using the random-effect model.

RESULTS

Seven eligible studies including 815 patients were analyzed. LAG was associated with less blood loss, less use of analgesics, shorter time of flatus and periods of hospital stay, but longer time of operation. The incidence of most complications was similar between the two groups. However, LAG was associated with a lower rate of pulmonary infection (odds ratio (OR) 0.19; 95% confidence interval (CI) 0.05 to 0.68; P<0.05). No significant differences were noted in terms of the number of harvested lymph nodes (weighted mean difference (WMD) 1.165; 95% CI -2.000 to 4.311; P>0.05), overall mortality (OR 0.65; 95% CI 0.39 to 1.10; P>0.05), cancer-related mortality (OR 0.64; 95% CI 0.32 to 1.25; P>0.05), or recurrence (OR 0.62; 95% CI 0.33 to 1.16; P>0.05).

CONCLUSIONS

LAG could be performed safely for AGC with adequate lymphadenectomy and has several short-term advantages compared with conventional OG. No differences were found in long-term outcomes. However, these results should be validated in large randomized controlled studies (RCTs) with sufficient follow-up.

Laparoscopic versus open total gastrectomy with D2 dissection for gastric cancer: a meta-analysis

OBJECTIVE

To elucidate the feasibility and safety of laparoscopic total gastrectomy with D2 dissection (LTGD2) for gastric cancer in comparison with open total gastrectomy with D2 dissection (OTGD2).

BACKGROUND

More surgeons have chosen laparoscopic total gastrectomy as an alternative to open total gastrectomy. But no meta-analysis has been performed to evaluate the value of LTGD2.

METHODS

Original articles compared LTGD2 and OTGD2 for gastric cancer, which published in English from January 1990 to March 2013 were searched in PubMed, Embase, and Web of Knowledge by two reviewers independently. Operative time, blood loss, harvested lymph nodes, analgesic medication, first flatus day, postoperative hospital stay, postoperative complications, and hospital mortality were compared using STATA version 10.1.

RESULTS

8 studies were selected in this analysis. A total of 1,498 patients were included (559 in LTG and 939 in OTG). LTGD2 showed longer operative time (WMD 39.29; 95 % CI 20.52, 58.06; P < 0.001), less blood loss (WMD -157.94; 95 % CI -245.25 -70.62; P < 0.001), fewer analgesic requirements (WMD -2.01; 95 % CI -3.10, -0.93; P < 0.001), earlier passage of flatus (WMD -0.73; 95 % CI -1.19, -0.27; P = 0.002), earlier hospital discharge (WMD -2.69; 95 % CI -3.42, -1.97; P < 0.001), and reduced postoperative morbidity (RR 0.70; 95 % CI 0.50, 0.98; P = 0.035). The number of harvested lymph nodes (WMD 0.27; 95 % CI -1.43, 1.98; P = 0.752) and hospital mortality rate (RR 0.57; 95 % CI 0.11, 3.09; P = 0.513) were similar.

CONCLUSION

LTGD2 was associated with less blood loss, less postoperative pain, quicker bowel function recovery, shorter hospital stay, and reduced postoperative morbidity, at the expense of longer operative time. No statistical differences were observed in lymph node dissection, and hospital mortality, which indicated the similar ability of lymph nodes clearance and short-term outcomes with OTGD2. A positive trend was indicated toward LTGD2. So we encourage the experienced surgeons to achieve LTGD2 instead of OTGD2. Whereas, due to non-randomized control trails and lack of long-term outcomes, more studies are required.

Systematic review and meta-analysis of laparoscopy-assisted and open total gastrectomy for gastric cancer

AIM: To evaluate the safety and efficacy of laparoscopy-assisted total gastrectomy (LATG) and open total gastrectomy (OTG) for gastric cancer.

METHODS: A comprehensive search of PubMed, Cochrane Library, Web of Science and BIOSIS Previews was performed to identify studies that compared LATG and OTG. The following factors were checked: operating time, blood loss, harvested lymph nodes, flatus time, hospital stay, mortality and morbidity. Data synthesis and statistical analysis were carried out using RevMan 5.1 software.

RESULTS: Nine studies with 1221 participants were included (436 LATG and 785 OTG). Compared to OTG, LATG involved a longer operating time [weighted mean difference (WMD) = 57.68 min, 95%CI: 30.48-84.88; P < 0.001]; less blood loss [standard mean difference (SMD) = -1.71; 95%CI: -2.48 - -0.49; P < 0.001]; earlier time to flatus (WMD= -0.76 d; 95%CI: -1.22 - -0.30; P < 0.001); shorter hospital stay (WMD = -2.67 d; 95%CI: -3.96 - -1.38, P < 0.001); and a decrease in medical complications (RR = 0.41, 95%CI: 0.19-0.90, P = 0.03). The number of harvested lymph nodes, mortality, surgical complications, cancer recurrence rate and long-term survival rate of patients undergoing LATG were similar to those in patients undergoing OTG.

CONCLUSION: Despite a longer operation, LATG can be performed safely in experienced surgical centers with a shorter hospital stay and fewer complications than open surgery.

Comparison of three different minimally invasive procedures of distal gastrectomy for Nonoverweight patients with T1N0-1 gastric cancer

Laparoscopic-assisted distal gastrectomy has recently come to be a standard procedure for the treatment of early gastric cancer (1 - 5) in select patients. The minimal invasiveness associated with laparoscopic procedures for the resection of gastrointestinal cancer has been repeatedly explained in part by the short incision that is required. (6 - 11) We used two different approaches to perform distal gastrectomies for the resection of gastric cancer as minimally invasive alternatives to a standard laparoscopic approach prior to our surgical team's complete mastery of the skills required for laparoscopic oncological surgery for gastric cancer. (9 , 12) If the minimal invasiveness associated with laparoscopic-assisted gastrectomy can be explained by the small incision, a gastrectomy via a small incision without the use of a pneumoperitoneum may provide a similar outcome in patients. However, to our knowledge, such a comparison has not been previously made. We compared the minimal invasiveness of three different approaches (minilaparotomy, minilaparotomy approach with laparoscopic assistance, and standard laparoscopic-assisted approach) to performing a distal gastrectomy for T1N0-1 gastric cancer in nonoverweight patients (body mass index, ≤ 25 kg/m(2)) performed within a limited study period.

Long-term outcomes of laparoscopy-assisted distal gastrectomy for early gastric cancer: result of a randomized controlled trial (COACT 0301)

BACKGROUND

The purpose of this study was to evaluate laparoscopy-assisted distal gastrectomy (LADG) compared to open distal gastrectomy (ODG) in the treatment of early gastric cancer with respect to survival, surgical outcomes, complications, and quality of life (QOL).

METHODS

One hundred sixty-four patients with cT1N0M0 and cT1N1M0 distal gastric cancer were randomly assigned to either the LADG group or the ODG group. The primary end point was the 5-year disease-free survival (DFS) rate. Complications were classified using the accordion severity classification of postoperative complications scheme. QOL was measured using the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-STO22 preoperatively and postoperatively during regular follow-up visits. This trial is registered at ClinicalTrials.gov (NCT00546468).

RESULTS

The median (range) follow-up period was 74.3 (24.8-90.8) months. The LADG and ODG groups showed similar survival [5-year DFS rate: 98.8 % vs. 97.6 %, respectively (P = 0.514), 5-year overall survival (OS) rate: 97.6 vs. 96.3 %, respectively (P = 0.721)] or overall complication rate (29.3 vs. 42.7 %, respectively; P = 0.073). Mild complications were significantly less frequent in the LADG group than in the ODG group (23.2 vs. 41.5 %; P = 0.012). The rates of moderate, severe, and long-term complications (i.e., 31 days to 5 years after surgery) did not differ significantly between groups. No clinically meaningful differences were detected between the two groups in long-term QOL.

CONCLUSION

LADG showed similar DFS and OS compared to ODG in treating early gastric cancer. Marginal benefits in mild complications were observed with LADG. LADG did not show advantages over ODG regarding other complications and long-term QOL.

Laparoscopy-assisted gastrectomy versus open gastrectomy for resectable gastric cancer: an update meta-analysis based on randomized controlled trials

BACKGROUND

We carry out a meta-analysis to evaluate the effectiveness and safety of laparoscopy-assisted gastrectomy (LAG) versus open gastrectomy for resectable gastric cancer.

METHODS

We searched EMBASE, the Cochrane Library, PubMed, Science Citation Index (SCI), Chinese biomedicine literature database to identify randomized controlled trials (RCTs) from their inception to April 2012. Meta-analyses were performed using RevMan 5.0 software. It was in line with the preferred reporting items for systematic reviews and meta-analyses statement. The quality of evidence was assessed by GRADEpro 3.6.

RESULTS

Eight RCTs totaling 784 patients were analyzed. Compared with open gastrectomy group, no significant differences were found in postoperative mortality (OR = 1.49; 95 % CI 0.29-7.79), anastomotic leakage (OR = 1.02; 95 % CI 0.24-4.27) , overall mean number of harvested lymph nodes [weighed mean difference (MD) = -3.17; 95 % CI -6.39 to 0.05]; the overall postoperative complication morbidity (OR = 0.54; 95 % CI 0.36-0.82), estimated blood loss (MD = -107.23; 95 % CI -148.56 to -65.89,) frequency of analgesic administration (MD = -1.69; 95 % CI -2.18 to -1.21, P < 0.00001), incidence of pulmonary complications (OR = 0.43, 95 % CI 0.20-0.93, P = 0.03) were significantly less in LAG group; LAG had shorter time to start first flatus (MD = -0.23; 95 % CI -0.41 to -0.05) and decreased hospital stay (MD = -1.72; 95 % CI -3.40 to 0.04), but, LAG still had longer operation time (MD = 76.70; 95 % CI 51.54-101.87).

CONCLUSIONS

On the basis of this meta-analysis we conclude that although LAG was still a time-consuming and technically dependent procedure, it has the advantage of better short-term outcome. Long term survival data from other studies are urgently needed to estimate the survival benefit of this technique.

Totally laparoscopic versus open gastrectomy for gastric cancer: a matched cohort study

BACKGROUND

The role of laparoscopic surgery for the treatment of gastric cancer is still controversial, particularly in terms of oncologic efficacy. The aim of this study was to compare short-term outcomes of laparoscopic and open resection for gastric cancer at a single Western institution.

SUBJECTS AND METHODS

This study was designed as a matched cohort study from a prospective gastric cancer database. Forty-one patients undergoing laparoscopic gastrectomy for gastric cancer between June 2008 and January 2012 were matched with 41 patients undergoing open gastrectomy in the same time period. Patient pairing was done according to age, gender, type of gastrectomy (subtotal or total), and tumor stage via a randomized statistical method. The short-term outcomes and oncologic adequacy of the laparoscopic and open procedures were compared. A D2 lymph node dissection was performed in the majority of patients in both groups.

RESULTS

The two study groups were similar with respect to patient and tumor characteristics. Laparoscopic procedures were associated with a decreased blood loss (118.7 versus 312.4 mL, P<.005), incidence of surgery-unrelated complications (3 versus 9 patients, P<.05), and duration of hospital stay (8.1 versus 11.5 days, P<.05) but increased operative time for both subtotal (223.5 versus 158.2 minutes, P<.001) and total (298.1 versus 185.5 minutes, P<.001) gastrectomies. The mean number of retrieved lymph nodes after D2 dissection was similar: 30.0 for laparoscopic and 29.7 for open patients.

CONCLUSIONS

Within the limitations of a nonrandomized analysis, this study shows that the laparoscopic approach is a safe and oncologically adequate option for the treatment of gastric cancer, which compares favorably with open gastrectomy in short-term outcomes.